Childhood Fever Capt. Rick Robbins Louisville Metro EMS
Introduction • What's is consider a fever • How do we assess a child with a fever • Causes • Management
FEVER • Defined as a rectal temp 100.5 or higher. • It usually arises due to a mild infection of the upper respiratory or gastrointestinal tract.
FEVER • Studies have shown that fever helps the immune system fight infections. • Most children are not particularly uncomfortable with fever, particularly if it is lower than 39.5ºC (103ºF).
FEVER Sometimes fever is caused by a serious medical condition, such as: Meningitis Pneumonia Bacterial infection of the blood. These are true medical emergencies. The initial assessment and focused history findings will usually indicate that the child’s condition is urgent
FEVER Fevers in a young infant is considered more urgent than fever in an older child. Any infant aged three months or younger who has a rectal temperature of 100.5 degrees Fahrenheit or higher should have be evaluated
FEVER Any child with fever who has decreased ability to fight infection should be considered potentially unstable. Transport the child for further medical evaluation, even if all assessment findings are normal.
FEVER If fever is accompanied by: • altered mental status • respiratory distress • signs of shock • seizures • bruise-like or spotty rash on the trunk or extremities • a stiff neck consider the child’s condition urgent.
FEVER • LOC • Awake • Irritable • Inconsolable by parents • unconscious
FEVER • Look, listen, and feel for air movement. • IS the airway is patent without positioning or suctioning. • Allow the child to remain in a position of comfort. • Position the airway as necessary. • Suction secretions as needed, giving high- concentration oxygen before and after suctioning. • A child with decreased responsiveness who is unable to maintain the airway should receive assisted ventilation using a bag-mask device.
FEVER • The normal breathing rate for the child’s age increases by approximately four to five breaths per minute for each degree Fahrenheit of fever. • The normal pulse rate for the child’s age increases by approximately ten to twelve beats per minute for each degree Fahrenheit of fever.
FEVER • Mild tachypnea is a common finding with fever. By itself not necessarily a problem. • Tachypnea, increased work of breathing, abnormal central skin color, or other abnormal respiratory findings, assume the child’s condition may be urgent.
FEVER • Check skin color and temperature as well as capillary refill time. • Measure blood pressure in children older than 3 years. • Mild tachycardia is a common finding in children with fever. • Signs of hypovolemic or septic shock are urgent findings. Compensated septic shock is indicated by warm, pink skin with normal or delayed capillary refill and bounding pulses.
FEVER • Test blood glucose levels in children with altered mental status and treat for hypoglycemia as indicated
HISTORY • Age—infants aged 2 months or younger have decreased ability to fight infection and should be transported if the temperature is 38ºC (100.5ºF) or higher • Headaches and emesis— the combination of fever, headaches, and emesis suggests meningitis, particularly if altered mental status is present as well.
HISTORY • Seizures—while febrile seizures are usually brief and do not harm the child, they may be a sign of meningitis • Poisoning—ingestions involving aspirin, certain antidepressants, and other drugs can cause fever; contact medical control or a poison control center for further instructions
HISTORY • Heart disease or pulmonary problems—children who have a history of heart disease or pulmonary problems may be unable to tolerate tachycardia and tachypnea associated with fever
HISTORY • Immunocompromise—children with sickle-cell anemia, HIV, nephrotic syndrome, a history of recent chemotherapy, autoimmune disorders , or a history of splenectomy have decreased ability to fight infection
HISTORY • The following findings also increase the child’s risk for serious complications of fever. • Compromised immune function due to • high-dose steroids, such as prednisone, taken for 2 weeks or longer • anti-rejection medications following an organ transplant
Increased risk of local bacterial infection due to hydrocephalus with a shunt congenital heart disease placement of a central intravenous catheter home peritoneal dialysis HISTORY
ASSESSMENT • Signs to look for during the detailed physical examination include • nuchal rigidity in a child or a distended fontanel in an infant, potential signs of meningitis • focal neurologic findings, such as unequal pupils or decreased unilateral movement, possibly indicating meningitis or a ventricular peritoneal shunt infection
ASSESSMENT • sunken eyes, lack of tears, dry mucous membranes, decreased skin turgor, and other signs of dehydration • petechiae, purpuric lesions, or any rapidly spreading skin rash • abdominal scar located in the left upper quadrant suggestion a splenectomy
MANAGEMENT • Any infant aged 2 months or younger who has a rectal temperature of 38ºC (100.5ºF) or higher should be evaluated by a physician, as there may be a serious bacterial infection requiring antibiotic treatment. • Children aged between 2 months and 3 years who have a rectal temperature exceeding 39.5ºC (103ºF) should also be considered urgent, as they may have occult infections in the blood or urine.
MANAGEMENT • Administer anti-pyretic agent if directed. • Cool with moisten lukewarm towels. • DONOT !!! use cold packs or ice. May cause shivering increasing temperature.
COMPLICATIONS • Febrile Seizures • Rashes • Septic Shock
FEBRILE SEIZURE • Febrile seizures are a potential complication of fever. • This type of seizure occurs most often in children aged 6 months to 6 years. About 5% of all children experience a febrile seizure before they are 6 years old.
FEBRILE SEIZURE • Many febrile seizures are of short duration, lasting less than 1 to 2 minutes. The majority last from 10 to 15 minutes.
FEBRILE SEIZURE • Simple febrile seizures involve tonic-clonic movements affecting the entire body. • All simple febrile seizures last less than 15 minutes, and most last only a minute or two. • They occur no more than once within a 24-hour period. • About one-third of children with simple febrile seizures will experience a recurrence, although usually not during the same illness.
FEBRILE SEIZURE • Complex febrile seizures begin with localized bodily movements. They can last longer than 15 minutes and may occur more than once within a 24-hour period. • In a few cases, febrile seizures may last longer than 30 minutes, in which case they are categorized as febrile status epilepticus.
FEBRILE SEIZURE • All reported seizures need to be transported. • Was it febrile, or new onset of problems other than fever?
RASHES • Many pediatric infections are accompanied by rashes. • Familiarizing yourself with the characteristics of these rashes can help you evaluate the seriousness of the child’s condition. • Accurately documenting rashes provides important information for hospital emergency department receiving personnel as rashes can progress.
RASHES • Purpuric versus viral rashes • Purpuric rashes consist of reddish-purple skin lesions that do not blanch on application of slight finger pressure. • Purpuric lesions can be either petechiae or ecchymoses. • Petechiae are small, flat lesions less than 2 mm in diameter.
RASHES • Ecchymoses are larger; they may be raised above skin level and are sometimes tender to the touch. • Purpuric lesions may denote loss of platelets or clotting factors due to disseminated infection or sepsis. • Purpuric rashes are more frequently bacterial than viral in origin.
RASHES • Viral rashes tend to be made up of erythematous lesions, which can be macular or papular. • These rashes usually blanch with slight finger pressure. • They tend to be diffusely located on the body. • Most start at the face or torso, spreading inferiorly toward the toes and laterally toward the extremities.
SEPTIC SHOCK • Septic shock Septic shock is a type of distributive shock associated with bacterial infection in the blood. In compensated septic shock, there is marked vasodilation, which causes blood pressure to drop as the blood supply fills a greater space.
Compensated Septic Shock Tachycardia Normal capillary refill time Warm, pink skin Bounding peripheral pulses Widened pulse pressure Other Compensated Shock Tachycardia Slow capillary refill time Cool, pale skin Weak peripheral pulses Narrow pulse pressure SEPTIC SHOCK Tachycardia
Temperature Measurement • Rectal temperature is considered the standard, as the rectum is insulated from environmental temperatures and has an excellent arterial blood supply • A parent’s tactile assessment of the child’s forehead identifies the presence of fever about50% to 75% of the time. The accuracy of axillary temperature readings is similar. • Heat-sensing strips placed on the forehead identify fever about 10% to 25% of the time.
Temperature Measurement • The accuracy of oral temperature measurement is adversely affected if the thermometer is not positioned correctly under the tongue. • Tympanic thermometers are rising in popularity, as they are less invasive than rectal measurement and have good reported accuracy.
Temperature Measurement • Temporal artery thermometers, a recent development in noninvasive temperature measurement, involve a probe that is placed over the forehead and moved laterally along the skin surface over the temporal artery just anterior to the ear. This device has reasonable accuracy. Children may find it more comfortable than a tympanic thermometer.
SUMMARY • Since it is not always possible to distinguish a mild infection from a life-threatening condition, any child with fever should be transported for further evaluation unless medical control directs otherwise. In children with fever, the presence of additional risk factors for infection, such as sickle-cell anemia or HIV, is cause for prompt transport and evaluation in the emergency department, even if all assessment findings are normal.
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Where to Get More Information • Other training sessions • List books, articles, electronic sources • Consulting services, other sources